Post-Coronary Artery Bypass Grafting (CABG) Management

Introduction to Antiplatelet Therapy

The American College of Cardiology recommends aspirin 75-100 mg daily as the cornerstone of post-CABG antiplatelet therapy for all patients, to be started within 6 hours after CABG surgery and continued indefinitely (Class I recommendation) 1
For patients undergoing CABG after acute coronary syndrome (ACS), P2Y12 inhibitor therapy should be resumed postoperatively to complete 12 months of dual antiplatelet therapy (DAPT) after ACS 2, 3

Aspirin 75-100 mg daily should be continued indefinitely (Class I recommendation) 1
Consider adding clopidogrel for 12 months to improve vein graft patency (Class IIb recommendation) 1, 2

P2Y12 inhibitor (preferably clopidogrel) plus aspirin should be resumed after CABG to complete a full 12-month course of DAPT after the ACS event 2, 3
After 12 months, continue aspirin monotherapy indefinitely 2, 3

Follow duration of DAPT based on PCI recommendations 2
P2Y12 inhibitor therapy should be resumed postoperatively to complete the recommended duration 2

Prasugrel should not be administered to patients with prior history of stroke or transient ischemic attack (TIA) 3
For patients with indications for oral anticoagulation (e.g., atrial fibrillation), direct oral anticoagulant (DOAC) is preferred over vitamin K antagonist unless contraindicated, and after initial period with triple therapy, transition to OAC plus clopidogrel for 6-12 months, followed by OAC alone, or OAC alone can be used for patients >12 months post-CABG who develop need for anticoagulation 4

The benefit of DAPT appears most pronounced in the first year after CABG, particularly for improving vein graft patency 1, 2
DAPT (aspirin plus P2Y12 inhibitor) may be considered in selected patients at higher risk of graft occlusion and low bleeding risk, with a Class IIb recommendation 5, 6, 3, 2
Clopidogrel is the preferred P2Y12 inhibitor after CABG, according to the European Heart Journal and the European Society of Cardiology 7, 8
Ticagrelor may be considered in specific high-risk ACS patients post-CABG, as it demonstrated reduction in cardiovascular mortality compared to clopidogrel in the PLATO trial subgroup analysis 6, 2

Proton pump inhibitor is recommended for patients at increased risk of gastrointestinal bleeding, as supported by the European Society of Cardiology and the American College of Cardiology 5, 9, 10, 2, 8
Consider proton pump inhibitor when using any antithrombotic therapy, based on individual bleeding risk, as recommended by the European Society of Cardiology 5
Early cessation of aspirin (≤1 week) is recommended to reduce bleeding risk, as stated by the European Society of Cardiology 5

P2Y12 inhibitors should be discontinued prior to elective CABG: clopidogrel ≥5 days before, ticagrelor ≥3 days before, and prasugrel ≥7 days before, as recommended by the American College of Cardiology 11
If possible, delay CABG after P2Y12 inhibitor discontinuation (5 days for clopidogrel, 3 days for ticagrelor, 7 days for prasugrel) to minimize bleeding risk, as recommended by the American College of Cardiology 11

High-intensity statin up to the highest tolerated dose is recommended by the European Society of Cardiology, with a target LDL-C level <1.4 mmol/L (55 mg/dL) and ≥50% reduction from baseline, as recommended by the European Atherosclerosis Society 5
ACE inhibitors should be started indefinitely in all patients with LVEF ≤40%, hypertension, diabetes, or chronic kidney disease, as recommended by the American College of Cardiology 12
Beta-blockers should be started and continued indefinitely in all post-MI patients unless contraindicated, as recommended by the American College of Cardiology 12
Target HbA1c <7% is recommended by the American Diabetes Association, with initiation of lifestyle modifications and appropriate pharmacotherapy, as recommended by the American College of Cardiology 13, 12